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INTRODUCTION
Breastfeeding is recognized to be one of the most successful approaches not just for the optimal growth and development and survival of the infant, but it is also a proven source of immense health benefits to the mother (Picó et al., 2021). An optimal diet, along with vital antibodies and immune systems provided by breast milk, is instrumental in reducing the risks of illnesses and hospitalizations not just in infants but also in their mother (American Academy of Pediatrics, 2022). However, despite the WHO guidelines for exclusive and prolonged infant and young child feeding to be practiced for the first six months of the infant’s life, the rate of exclusive breastfeeding has not been optimal (Hossain et al., 2018). Though the rate of exclusive breastfeeding has improved from 37% in 2012 to 48% at present (Jumu, 2017), still hardly half of the infants in the world are receiving the benefits of optimal levels of breast-feeding (Chezem, 2012). Huge differences in the rates of exclusive breast-feeding are still there among the countries, depending upon healthcare support, factors for the protection of motherhood, and the enforcement of the WHO Code (World Health Organization, 2023). The WHO Global Breastfeeding Scorecard highlights further the importance of financial investment by stating that “over 85% of all countries reported public spending below recommended levels of US$4.70 per facility birth on breastfeeding support (UNICEF, 2022). Systemic issues in investment efforts are then exacerbated by medical ones faced by lactating mothers, particularly in instances of C-section births, which include pain, reduced physical movement, wait times prior to breastfeeding initiation, as well as difficulties in achieving comfortable positioning for infants to properly latch on to for successful breastfeeding to occur (Srinivasan, 2006). Both positioning and lactation are central to successful breastfeeding practices because physical comfort is necessary for efficient feeding and influencing feeding behavior (Kifle et al., 2018). Evidence suggests that alternative breastfeeding positions, such as side-lying and football holds, may enhance maternal comfort and promote favourable infant feeding behaviours in post-caesarean mothers when compared to conventional cradle hold positioning (Pehlivan and Demirel Bozkurt, 2021). Therefore, there is a compelling need to systematically evaluate breastfeeding positions that improve maternal comfort and infant feeding behaviour following Caesarean delivery, thereby contributing to improved breastfeeding outcomes and supporting global efforts to achieve optimal exclusive breastfeeding rates (Najahah, 2024).
MATERIALS AND METHODS
A quasi-experimental, non-randomized comparative study was conducted in the postnatal ward of Dhiraj General Hospital, Sumandeep Vidyapeeth (Deemed to be University), Vadodara, Gujarat, after obtaining approval from the Institutional Ethics Committee (SVIEC/ON/NURS/SRP/May/24/78).
Eighty post-caesarean mothers were selected using purposive sampling. Eligible participants were alternately allocated to either the cradle hold group (Group 1, n=40) or the football hold group (Group 2, n=40) to ensure equal group size. Randomization was not employed. Mothers with postpartum complications or medical illnesses were excluded. Written informed consent was obtained from all participants.
Maternal comfort during breastfeeding was assessed using a Visual Analog Scale, while infant feeding behaviour was evaluated using the Infant Breastfeeding Assessment Tool, which assesses latch, sucking, swallowing, and positioning. Data were collected at 48 hours postpartum.
The research tool for data collection it consists two section:
- Section A: Consists of items on demographic variables like are age, education, occupation, religion, habitat, family type, age of newborn, parity, gender of newborn, birth weight.
- Section B: Checklist for Maternal comfort and infant feeding behaviour.
All study instruments were validated by seven subject experts and pilot-tested to establish reliability. Each day, four participants were enrolled and evenly allocated to the two study groups. Data were analysed using SPSS version 25.0. Descriptive statistics including mean, standard deviation, frequency, and percentage were used to summarize baseline characteristics. The independent sample t-test was applied to compare mean maternal comfort and infant feeding behaviour scores between the two groups. The chi-square test was used to assess associations between breastfeeding position and selected maternal and neonatal variables. A p-value <0.05 was considered statistically significant.
RESULTS
Socio-Demographic Characteristics of Caesarean Section Mothers
In Group 1 (Cradle Hold), most of the mothers were between the age group of 20-25 years (52.5%), by those aged below 20 years (25.0%) and 26-30 years (22.5%). With regard to educational status 32.5% had higher secondary educational attainment, 30.0% had primary or secondary schooling, 22.5% were illiterate, and 15.0% were graduates. With respect to occupation, 50.0% were housewives, 40.0% were private employees, while 5.0% each were government employees and self-employed. Most mothers belonged to the Hindu religion (85.0%), resided in rural areas (55.0%), and lived in joint families (60.0%).
In Group 2 (Football Hold), half of the mothers (50.0%) were aged 20-25 years, followed by 26-30 years (30.0%) and below 20 years (20.0%). Educational status showed that 32.5% had higher secondary education, 32.5% had primary or secondary education, 25.0% were illiterate, and 10.0% were graduates. Regarding occupation, 47.5% were housewives, 40.0% were private employees, 7.5% were self-employed, and 5.0% were government employees. The majority were Hindu (77.5%), lived in rural areas (52.5%), and belonged to nuclear families (52.5%) (Table 1).
| Demographic characteristics | Cradle hold Group-1 Frequency | Percentage % | Football hold Group-2 Frequency | Percentage % |
|---|---|---|---|---|
| Age groups | ||||
| <20 yrs | 10 | 25 | 8 | 20 |
| 20-25 yrs | 21 | 52.5 | 20 | 50 |
| 26-30 yrs | 9 | 22.5 | 12 | 30 |
| Education | ||||
| Primary/secondary | 12 | 30 | 13 | 32.5 |
| Higher secondary | 13 | 32.5 | 13 | 32.5 |
| Graduate | 6 | 15 | 4 | 10 |
| Illiterates | 9 | 22.5 | 10 | 25 |
| Occupation | ||||
| House wife | 20 | 50 | 19 | 47.5 |
| Government employee | 2 | 5 | 2 | 5 |
| Private employee | 16 | 40 | 16 | 40 |
| Self-employee | 2 | 5 | 3 | 7.5 |
| Religion | ||||
| Hindu | 34 | 85 | 31 | 77.5 |
| Muslim | 6 | 15 | 9 | 22.5 |
| Residence | ||||
| Rural | 22 | 55 | 21 | 52.5 |
| Urban | 18 | 45 | 19 | 47.5 |
| Family type | ||||
| Nuclear | 16 | 40 | 21 | 52.5 |
| Joint | 24 | 60 | 19 | 47.5 |
| Total | 40 | 100 | 40 | 100 |
Comparison of Mean Maternal Comfort and Infant Feeding Behaviour Scores
Comparison of mean maternal comfort and infant feeding behaviour scores between mothers practicing the cradle hold and football hold breastfeeding positions using an independent t-test. Each group consisted of 40 caesarean section mothers. The results indicate that mothers in the cradle hold group had a higher mean score (Mean=51.93, SD=4.99) compared to mothers in the football hold group (Mean=39.15, SD=4.43). The calculated t-value was 12.11, and the obtained p-value was less than 0.05, indicating a statistically significant difference between the two groups (Table 2).
| Groups | n | Mean | SD | SE | t-value | p-value |
|---|---|---|---|---|---|---|
| Cradle hold | 40 | 51.93 | 4.99 | 0.79 | 12.1106 | 0.05* |
| Football hold | 40 | 39.15 | 4.43 | 0.7 |
Comparison of Breastfeeding Positions with Levels of Maternal Comfort and Infant Feeding Behaviour
Comparison of the levels of maternal comfort and infant feeding behaviour among caesarean section mothers practicing the cradle hold and football hold breastfeeding positions. The levels were categorized as poor (<Q1), average (Q1-Q3), and good (>Q3) based on the obtained scores.
In the cradle hold group, none of the mothers (0.0%) were found to have a poor level of maternal comfort and infant feeding behaviour. Half of the mothers (50.0%) exhibited an average level, while the other 50.0% rated at a good level, showing a positive outcome with the cradle hold position. However, for the football hold group, 40.0% of mothers were classified under the poor level category, 60.0% had an average level, and none (0.0%) had achieved a good level of maternal comfort and infant-feeding behaviour. b. Chi-square analysis indicated a statistically significant difference between the two groups (χ2=36.36, p<0.05) (Table 3).
| Levels | Cradle hold | % | Football hold | % | Total | % | Chi-square | p-value |
|---|---|---|---|---|---|---|---|---|
| Poor level (<Q1) | 0 | 0 | 16 | 40 | 16 | 20 | 36.36 | 0.005* |
| Average level (Q1 to Q3) | 20 | 50 | 24 | 60 | 44 | 55 | ||
| Good level (>Q3) | 20 | 50 | 0 | 0 | 20 | 25 | ||
| Total | 40 | 100 | 40 | 100 | 80 | 100 |
Association between Breastfeeding Position and Maternal Characteristics
As for the age of the infant, it is to be noted that the great majority of the babies in the cradle hold group fall within the first week. (55.0%) and the football hold group (50.0%) were 4-7 days old. By chi-square test, no statistically significant association between breastfeeding position and age of the newborn (χ2=0.583, p=0.747). As far as parity, 52.5% of mothers in the cradle hold group and 57.5% in the football hold group were multiparous, while 47.5% and 42.5%, respectively, were Primiparous. The association between breastfeeding position and parity was found to be statistically significant (p<0.05), indicating that parity had a significant influence on maternal comfort and infant feeding behaviours, particularly in the cradle hold position. Regarding the gender of the newborn, male and female infants were almost equally distributed in both groups. The chi-square value (χ²=0.450, p=0.502) indicated no significant association between breastfeeding position and newborn gender. With respect to birth weight, the majority of newborns in both groups weighed 2-3 kg (cradle hold: 67.5%; football hold: 60.0%). The association between breastfeeding position and birth weight was not statistically significant (p=0.739) (Table 4).
| Maternal characteristics | Cradle hold | % | Football hold | % | Total | % | Chi-square | p-value |
|---|---|---|---|---|---|---|---|---|
| Age of new born | ||||||||
| <=3 days | 9 | 22.5 | 8 | 20 | 17 | 21.25 | 0.583 | 0.747 |
| 4-7 days | 22 | 55 | 20 | 50 | 42 | 52.5 | ||
| >7 days | 9 | 22.5 | 12 | 30 | 21 | 26.25 | ||
| Parity | ||||||||
| Primi | 19 | 47.5 | 17 | 42.5 | 36 | 45 | 0.202 | 0.002S |
| Multi | 21 | 52.5 | 23 | 57.5 | 44 | 55 | ||
| Gender of new born | ||||||||
| Male | 21 | 52.5 | 18 | 45 | 39 | 48.75 | 0.45 | 0.502 |
| Female | 19 | 47.5 | 22 | 55 | 41 | 51.25 | ||
| Birth weight | ||||||||
| 1-2 kg | 9 | 22.5 | 12 | 30 | 21 | 26.25 | 0.605 | 0.739 |
| 2-3 kg | 27 | 67.5 | 24 | 60 | 51 | 63.75 | ||
| >3 kg | 4 | 10 | 4 | 10 | 8 | 10 | ||
| Total | 40 | 100 | 40 | 100 | 80 | 100 |
DISCUSSION
The study findings revealed a significantly higher mean maternal comfort and infant feeding behaviour score in the cradle hold group compared to the football hold group (p<0.05). This suggests that the mothers practicing the cradle technique felt more comfortable and reported improved infant feeding practices post-caesarean section.
The findings of the present study demonstrate significantly higher maternal comfort and improved infant feeding behaviour among post-caesarean mothers using the cradle hold position compared to the football hold position. This may be attributed to reduced abdominal strain, enhanced mother-infant contact, and easier positioning, which are particularly important following surgical delivery (Raj et al., 2018; Ojukwu et al., 2022) reported that mothers who practiced the cradle hold experienced reduced shoulder strain and greater confidence during breastfeeding compared with other positioning techniques. Similarly, a randomized trial demonstrated significantly higher maternal comfort scores among post-caesarean women using the cradle hold position (Chooi et al., 2012).
Pain and limited arm movement following child delivery cause significant impediments to breastfeeding after caesarean section (Dunn and O'Herlihy, 2005). The cradle hold can prevent unnecessary pressure on the abdomen and enable a more natural posture for feeding once the mothers are stable (Schenkel, 2020), which could account for the increased comfort scores found in the current study.
Analysis of comfort and levels of feeding behaviours showed that there were no mothers in the the cradle hold group experienced poor comfort, whereas 40% of mothers in the football hold group belonged to the poor group. Moreover, 50% of the mothers in the cradle hold group reached a good level of comfort and feeding behavior, accompanied by none in the football hold group achieved this level. The difference was statistically significant (p<0.05).
These findings indicate that the cradle hold is more effective in promoting optimal breastfeeding experiences after a Caesarean section (Disorntatiwat et al., 2023). Similar results were observed identified that the mothers with the cradle hold were able to latch their infants better and for longer periods, the duration of the feeding process, and the number of interruptions to the feeding process that occurred when the alternative holds (Dawson et al, 2022).
The lack of good-level outcomes in the football hold group can be traced back to difficulties in posture maintenance, arm weakness, and positioning difficulties, particularly amongst first-timers mothers undergoing surgery repairs (Hashizume et al., 2018).
The results of the current study point to the important role played by nurses/midwives in teaching post-caesarean mothers how to breastfeed correctly. Training mothers in the "cradle hold" technique in the immediate postpartum period could make a considerable impact in improving the comfort levels of the mother and the infant-feeding practices (Hennessy, 2021). Addition of the structured breast-feeding integration of position counselling into protocols of post-operative nursing care practice has been shown to have a positive effect outcomes and maternal satisfaction (Smyth, 2016).
CONCLUSION
The study concludes that both cradle hold and football hold positions are acceptable breastfeeding techniques for post-caesarean mothers. However, the cradle hold position was associated with significantly higher maternal comfort and improved infant feeding behaviour compared to the football hold position. Structured breastfeeding position counselling by nurses and midwives during the early postoperative period may enhance maternal comfort and breastfeeding outcomes. Further studies with larger samples and randomized designs are recommended. Prenatal training should be provided to mothers on all breastfeeding positions. Further studies with larger sample size are warranted to better understand the relationships between incision pain after cesarean section, breastfeeding positions, and breastfeeding success. The study highlights the crucial role of nurses and midwives in educating post-caesarean mothers on appropriate breastfeeding positions. Early training in the cradle hold technique can enhance maternal comfort, feeding efficiency, and overall breastfeeding satisfaction.